Racial differences in breast cancer survival in a large urban integrated health system

Abstract

BACKGROUND: African American (AA) women are known to have poorer breast cancer survival than whites, and the differences may be related to underlying disparities in their clinical presentation or access to care. This study evaluated the relationship between demographic, treatment, and socioeconomic factors and breast cancer survival among women in southeast Michigan. METHODS: The population included 2387 women (34% AA) with American Joint Committee on Cancer stage I to III breast cancer who were treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked data sets from the HFHS, the Metropolitan Detroit Cancer Surveillance System, and the US Census Bureau were used to obtain demographic and clinical information. Comorbidities were classified with the modified Charlson comorbidity index (CCI). Economic deprivation was categorized with a census tract-based deprivation index (DI), which was stratified into 5 quintiles of increasing socioeconomic disadvantage. RESULTS: Compared with whites, AA women were significantly more likely to have larger, hormone receptor-negative tumors and more comorbidities and to reside in an economically deprived area. In an unadjusted analysis, AAs had a significantly higher risk of death (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.16-1.59); however, after adjustments for clinical (age, stage, hormone receptor, and CCI) and societal factors (DI), the effect of race was not significant (HR, 1.13 [95% CI, and HR,] respectively). CONCLUSIONS: Racial differences in breast cancer survival can be explained by clinical and socioeconomic factors. Nonetheless, AA women with breast cancer remain disproportionately affected by unfavorable tumor characteristics and economic deprivation, which likely contribute to their increased overall mortality. Cancer 2015;121:3668-75.

Racial disparities in individual breast cancer outcomes by hormone-receptor subtype, area-level socio-economic status and healthcare resources

“…Socioeconomic status has been shown to influence breast cancer survival outcomes when measured at both individual and area levels, with results consistently showing worse outcomes for patients with lower individual and/or area-level SES [7, 19, 23]. Fewer studies have examined other area-level factors such as access to healthcare resources [4, 24, 25], while most studies have focused on examining insurance status. However, area-level availability of healthcare resources likely plays a key role in breast cancer survival outcome through the receipt of timely and high-quality treatment, which in turn influences survival.…”

Racial and Ethnic Differences in End‐of‐Life Medicare Expenditures

“…In this way, EOL expenditures are unlike many other health outcomes that have been evaluated for the effects of race and ethnicity. Prior studies have demonstrated that other mechanisms, such as socioeconomic status, health literacy, clinical factors, hospital‐ or neighborhood‐level effects, or insurance status, can explain what often appears to be a race effect on health outcomes . Although the current study included these factors, all of which somewhat attenuated the measured association between EOL Medicare expenditures and racial and ethnic groups, they failed to explain the total difference.…”

“…Prior studies have demonstrated that other mechanisms, such as socioeconomic status, health literacy, clinical factors, hospital-or neighborhood-level effects, or insurance status, can explain what often appears to be a race effect on health outcomes. 3,4,9,11,[42][43][44][45] Although the current study included these factors, all of which somewhat attenuated the measured association between EOL Medicare expenditures and racial and ethnic groups, they failed to explain the total difference. This highlights how complexities surrounding care and decision-making at the EOL can be difficult to capture.…”

“…An extensive body of evidence documents racial and ethnic differences in medical care at the end‐of‐life (EOL) . These include differences reported in intensity of care, individual preferences, and Medicare spending .…”

“…A n extensive body of evidence documents racial and ethnic differences in medical care at the end-of-life (EOL). [1][2][3][4][5][6][7][8][9][10][11][12][13][14] These include differences reported in intensity of care, individual preferences, and Medicare spending. 2,3,7,8,15 Medicare spending for black decedents has been found to be between 28% and 37% higher than for white decedents.…”